Post-discharge telephone calls may reduce hospital readmissions

By Sara Saldi

“We will also study how to implement a system of two-way communication, alerting the primary care clinic immediately about their patient’s hospital discharge and transmitting the results of the back to the hospital and other providers.”

Sharon Hewner, PhD, RN, assistant professor of nursing

University at Buffalo

BUFFALO, N.Y. -- It’s an all too familiar story: a
patient—specifically a patient with chronic
disease—goes into the hospital to get well and is discharged
only to be readmitted within 30 days. Medicare spends $15 billion a
year on readmissions alone.

It turns out that better communication to patients and their
physicians about follow-up care might be one way to prevent a
return to the hospital or emergency room.

The Agency for Healthcare Research and Quality (AHRQ) has
awarded the University at Buffalo School of Nursing a grant of
$298,934 over a two-year period to create a pilot project whose
goal is to work with primary care physician’s offices, their
patients and families to see that patients get follow-up care very
soon after leaving the hospital.

Sharon Hewner, PhD, RN, assistant professor of nursing and
author of the grant is a specialist in population health analysis,
health services research, and informatics.

Hewner says that there has been a lack of timely communication
between the hospital and community setting.

“Our project will use the electronic health record to
exchange health information across settings in real time,”
she says, “and provide decision support to nurse care
coordinators in primary care offices to proactively prevent
re-hospitalization.”

As part of the study, Hewner says they will use the “Care
Transitions Dashboard” to incorporate an alert message about
a hospital discharge from the regional health information
organization, HEALTHeLINK™, with information from the
electronic health record at Elmwood Health Center, an affiliate of
People Inc.

The “dashboard” will help guide the nurse care
coordinator in developing an individualized plan of care
specifically to prevent re-hospitalization through its structured
assessment of social factors such as health literacy, home
environment, and financial resource issues that may increase the
complexity of care after leaving the hospital.

According to Hewner, most post-discharge intervention studies
focus on a single disease, such as heart failure, and not a variety
of chronic health problems or patients with a number of
interdependent health issues.

“Our study will try to improve the identification of
patients who are at-risk for being readmitted by using the
COMPLEXedex™, a hierarchical algorithm which divides the
population into healthy, at-risk, chronic and complex cohorts based
on nine prevalent chronic conditions,” says Hewner.

Health outcomes such as readmissions and emergency department
visits in the 90 days after discharge will be compared with another
primary care practice using data from the New York State Medicaid
Data Warehouse.

U. S. Representative for New York’s 26th district, Brian
Higgins, said that he applauds efforts to improve health care
delivery in fiscally smart ways in Western New York.

"Through this federally-supported project, the UB School of
Nursing is creating a model for proactive post hospitalization
health care delivery,” says Higgins. “Their leadership,
community coordination and electronic medical record integration
aim to lower long term costs and improve health care
outcomes.”

Hewner says the study design is significant because it promotes
a low-cost, targeted intervention—a health care coordinator
using telephone outreach to patients guided by an organized
assessment—to ensure that the care is more patient-centered
and takes into account that this may be a time when the patient is
vulnerable and therefore likely to misinterpret instructions and be
too preoccupied, or ill, to arrange follow-up with a primary care
health provider on their own.

“We will also study how to implement a system of two-way
communication, alerting the primary care clinic immediately about
their patient’s hospital discharge and transmitting the
results of the back to the hospital and other providers,”
says Hewner.

“Our working hypothesis is that timely notification in the
form of discharge alerts and system-wide understanding of the
patient’s condition and their social and medical complexity
will reduce follow-up time and encourage better patient
outcomes.”

Hewner says that the intended outcome of the study would be to
develop an automated system, the Care Transitions Dashboard, to
notify the primary care practice of real-time discharge and for
post-discharge follow-up to happen ideally with 72 hours of
discharge.

“The project lays the groundwork for future research
focused on sustaining the improvement through securing
reimbursement for outreach, evaluating the most cost-effective
interventions, and customizing outreach for different
populations,” she says.

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